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    Exam Review

    1. A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I?
      A)
      Have the client identify a specific scent
      B)
      Observe the facial symmetry when asked to smile
      C)
      Assess the pupillary response to light
      D)
      Use a tongue blade to check the gag reflex
    2. Which of the following is an expected finding when assessing intra-thoracic lymph nodes?
      A)
      Enlarged and tender lymph nodes
      B)
      Fixed and hard lymph nodes
      C)
      Non-palpable lymph nodes
      D)
      Soft and mobile lymph nodes
    3. The nurse auscultates crackles in the posterior left lung during a physical examination. Which type of data is this?
      A)
      Subjective data
      B)
      Secondary data
      C)
      Objective data
      D)
      Historical data
    4. A nurse is caring for a client who is experiencing urinary incontinence. Which of the following actions should the nurse take?
      A)
      Limit fluid intake to 500 mL per day
      B)
      Provide a bedside commode
      C)
      Apply a moisture barrier ointment
      D)
      Insert an indwelling urinary catheter
    Page 1 of 16

    Exam Review

    1. Which of the following findings in a client's respiratory assessment should be considered unexpected and require immediate action?
      A)
      Respiratory rate of 16 breaths per minute
      B)
      Symmetrical chest expansion
      C)
      Use of accessory muscles to breathe
      D)
      Resonance heard upon percussion
    2. When conducting a general survey, how should the nurse interpret the client's body language?
      A)
      Interpret body language in isolation
      B)
      Only use it as a minor aspect of communication
      C)
      Multi-faceted interpretation integrated with verbal cues
      D)
      Use only the spoken answers during the survey
    3. A client presents with chest pain, shortness of breath, and a recent history of diarrhea. Upon assessment, the nurse notes an irregular heart rhythm and low potassium levels in the lab results. What is the most appropriate nursing action to take next?
      A)
      Assess the client's vital signs and reassess heart rhythm before taking further action
      B)
      Document findings for future reference and take no immediate action
      C)
      Administer potassium without consulting the healthcare provider
      D)
      Initiate oxygen therapy immediately without further assessment
    4. A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?
      A)
      I need to drink apple cider vinegar each day
      B)
      I will need to empty my bladder regularly and completely
      C)
      I need to drink 2 L of fluid each day
      D)
      I need to wipe my perineal area from back to front after urination
    Page 2 of 16

    Exam Review

    1. A nurse is assessing an adult client and notes an increased respiratory rate of 28 breaths per minute and an oxygen saturation level of 89% on room air. Based on these findings, which of the following interventions should the nurse prioritize?
      A)
      Administer oxygen therapy to improve the oxygen saturation level
      B)
      Encourage the client to take deep breaths to improve lung expansion
      C)
      Document the findings and monitor the client closely for changes
      D)
      Position the client in a high-Fowler’s position
    2. A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following manifestations should the nurse expect?
      A)
      Decreased urine output
      B)
      Flank pain
      C)
      Hematuria
      D)
      Increased urinary frequency
    3. During a head-to-toe examination, which finding requires further investigation of the skin?
      A)
      Even pigmentation
      B)
      Smooth texture
      C)
      Absence of lesions
      D)
      A new mole with irregular borders
    4. Which unexpected finding in a client's ocular assessment requires urgent attention?
      A)
      Pupils equal and reactive to light
      B)
      Sudden onset of vision loss
      C)
      Peripheral vision intact
      D)
      Clear conjunctiva
    Page 3 of 16

    Exam Review

    1. When assessing the apical pulse of a client, which of the following is the most important anatomical landmark for accurate placement of the stethoscope?
      A)
      Right second intercostal space at the sternal border
      B)
      Left shoulder region near the acromion process
      C)
      Left fifth intercostal space at the midclavicular line
      D)
      Mid-sternum at the angle of Louis
    2. The client describes burning pain in their legs after walking for 10 minutes. How should the nurse categorize this data?
      A)
      Objective data
      B)
      Documented findings
      C)
      Subjective data
      D)
      Physical observation
    3. The nurse notes that a client's urinary frequency is paired with small voids. Which additional finding would most likely indicate urinary retention?
      A)
      High urine specific gravity
      B)
      Suprapubic distention and tenderness
      C)
      Polyuria
      D)
      Clear, pale yellow urine
    4. A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VIII?
      A)
      Whisper in one of the client's ears while occluding the other
      B)
      Have the client identify specific smells
      C)
      Observe for facial symmetry while the client smiles
      D)
      Check the client's visual acuity using a Snellen chart
    Page 4 of 16

    Exam Review

    1. A nurse is teaching a client about the benefits of passive range of motion (ROM) exercises. Which of the following descriptions by the client indicates a correct understanding?
      A)
      Prevents bone degeneration
      B)
      Prevents muscle atrophy
      C)
      Increases muscle mass
      D)
      Maintains joint mobility
    2. A nurse is collecting data with the parent of a newborn. Which of the following statements should the nurse make?
      A)
      A baby with colic needs medication to treat their pain.
      B)
      Colic is caused by a medical condition.
      C)
      Crying due to colic is usually louder and more high pitched.
      D)
      Colic most commonly occurs in the morning.
    3. A nurse is teaching a class about the process of digestion. The nurse should include that the final chemical acting on the food at the stomach location is ________
      A)
      Lipase
      B)
      Pepsin
      C)
      Amylase
      D)
      Bile
    4. A client with a history of benign prostatic hyperplasia (BPH) presents with urinary hesitancy and weak stream. Which finding during assessment would be expected?
      A)
      Bladder emptying without residual urine
      B)
      Bladder pain and discomfort
      C)
      Urinary frequency with small amounts
      D)
      Nocturia with frequent urination at night
    Page 5 of 16

    Exam Review

    1. A client with a history of benign prostatic hyperplasia (BPH) presents with urinary hesitancy and weak stream. Which finding during assessment would be expected?
      A)
      Bladder emptying without residual urine
      B)
      Bladder pain and discomfort
      C)
      Urinary frequency with small amounts
      D)
      Nocturia with frequent urination at night
    2. During a head-to-toe assessment, which finding in the neck area requires immediate intervention?
      A)
      Palpable lymph nodes
      B)
      Symmetrical thyroid gland
      C)
      Tracheal deviation from midline
      D)
      Visible jugular venous pulsation
    3. A nurse is performing a physical assessment on a patient. Which sequence should the nurse follow?
      A)
      Auscultation, palpation, percussion, inspection
      B)
      Inspection, percussion, palpation, auscultation
      C)
      Inspection, palpation, percussion, auscultation
      D)
      Palpation, inspection, percussion, auscultation
    4. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?
      A)
      Distended neck veins
      B)
      High blood pressure
      C)
      Dark colored urine
      D)
      Increased skin turgor
    Page 6 of 16